Adding cognitive behavioral therapy -- an approach that teaches skills for handling life challenges and revising negative thought patterns -- to pharmaceutical treatment for attention-deficit hyperactivity disorder (ADHD) significantly improved symptom control in a study of adult patients. The report from Massachusetts General Hospital (MGH) researchers appear in the August 25 Journal of the American Medical Association.

"Medications are very effective in 'turning down the volume' on ADHD symptoms, but they do not teach people skills," explains Steven Safren, PhD, ABPP, director of Behavioral Medicine in the MGH Department of Psychiatry, who led the study. "This study shows that a skills-based approach can help patients learn how to cope with their attention problems and better manage this significant and impairing disorder."

More than 4 percent of adults in the U.S. have ADHD, and while stimulants and other psychiatric medications are the primary first-line treatment, the study authors note that a significant number of patients who take and respond to these medication are still troubled by continuing symptoms. A few studies have investigated psychosocial treatment for ADHD, and although some have suggested benefits from cognitive behavioral therapy, they were small and short-term. The current study is believed to be the first full-scale randomized, controlled trial of the effectiveness of an individually-delivered, non-medication treatment of ADHD in adults.

The study enrolled adults diagnosed with ADHD who reported reduced but still significant symptoms while taking an ADHD medication. Randomly assigned to one of two therapeutic approaches, participants attended 12 weekly one-on-one counseling sessions with a psychologist or psychology fellow. The control group received training in muscle relaxation and other relaxation techniques, education on how to apply relaxation to ADHD symptoms, and supportive psychotherapy. The cognitive behavioral therapy sessions included skills training in areas such as organization and planning, setting priorities and problem solving, coping with distractions, and developing adaptive thought responses to stressful situations.

"Sessions were designed specifically to meet the needs of ADHD patients and included things like starting and maintaining calendar and task list systems, breaking large tasks into manageable steps, and shaping tasks to be as long as your attention span will permit," Safren says. "The treatment is half like taking a course and half like being in traditional psychotherapy."

Symptom assessments conducted at the end of the 12-week treatment period revealed that participants receiving cognitive behavioral therapy had significantly better symptom control than did those receiving relaxation training, benefits that were maintained three and nine months later. A standard rating scale for ADHD symptoms showed a 30 percent reduction in symptoms in more than two thirds of the cognitive behavioral therapy group but in only one third of the relaxation group.

"We know that ADHD medications are effective for patients who can take them, and without medications it would be harder to learn the skills taught in this study," Safren adds. "But we have shown that learning self-management skills can help reduce symptoms even further. Now we need to determine the best ways to train clinicians in this approach and the best time to introduce this treatment, along with exploring other ways to help patients who did not benefit." Safren is an associate professor of Psychology in the Harvard Medical School Department of Psychiatry.

Additional co-authors of the study, which was supported by a grant from the National Institute of Mental Health, are Susan Sprich, PhD, Matthew Mimiaga, ScD, MPH, Craig Surman, MD, Laura Knouse, PhD, and Meghan Groves -- all of MGH Psychiatry -- and Michael Otto, PhD, formerly of MGH Psychiatry and now at Boston University.

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